Environmental Engineering Reference
In-Depth Information
tABleĀ 3.6
Accident Investigation report Form
ACCIDENT.NUMBER:.. ____________________________________________________________________
COMPANY.. ___________________________ . ADDRESS.._______________________________________
DEPARTMENT.OR.LOCATION.OF.ACCIDENT.IF.DIFFERENT.THAN.ABOVE:
_________________________________________________________________________________________
WHO.WAS.INJURED,.ILL,.OR.DIED?
NAME.OF.INJURED.. _____________________.SOCIAL.SECURITY.NUMBER. .____________________
SEX.. _________ .AGE.. .________ .DATE.OF.BIRTH.. .__________ .DATE.OF.ACCIDENT. .__________
HOME.ADDRESS.._______________________________ .TELEPHONE.#. .__________________________
EMPLOYEE'S.USUAL.OCCUPATION..________________________________________________________
OCCUPATION.AT.TIME.OF.ACCIDENT..______________________________________________________
LENGTH.OF.EMPLOYMENT..__________ .TIME.IN.OCCUP..AT.TIME.OF.ACCIDENT. . _____________
EMPLOYMENT.CATEGORY.. ___________________________________________________ .(i.e.,.full.time)
TYPE.OF.INJURY.. _____________________________ .PART.OF.BODY. .__________________________
SEVERITY.OF.THE.INJURY.. _______________________________________________________________
NAMES.OF.OTHERS.INJURED.IN.SAME.ACCIDENT
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
WHEN.DID.THE.ACCIDENT.OCCUR?
DATE.OF.ACCIDENT.______________________ .TIME.OF.ACCIDENT. .__________________________
SHIFT.. __________________________________________________________________________________
WHERE.DID.THE.ACCIDENT.OCCUR?
LOCATION.OF.ACCIDENT.._________________________________________________________________
ON.EMPLOYER'S.PREMISE?.. ______________________________________________________________
ACTIVITY.AT.TIME.OF.ACCIDENT.._________________________________________________________
SUPERVISOR.IN.CHARGE.._________________________________________________________________
WHAT.HAPPENED.OR.CAUSED.THE.ACCIDENT?
DESCRIBE.HOW.THE.ACCIDENT.OCCURRED
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
DESCRIBE.THE.ACCIDENT.SEQUENCE
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
CAUSAL.FACTOR
_________________________________________________________________________________________
_________________________________________________________________________________________
HOW.CAN.IT.BE.PREVENTED.FROM.OCCURRING.AGAIN?
CORRECTIVE.ACTIONS
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PREPARED.BY..___________________________________________________________________________
TITLE.. __________________________________________________________________________________
DEPARTMENT..___________________________________________________________________________
SIGNATURE..___________________________________________ .DATE. .__________________________
 
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